Dizziness

L. Jay Turkewitz MD

Dizziness

• One of the most common complaints in all practice

• Affects 20-30% of the population• I have been hospitalized twice in my life with

severe vertigo and uncontrolled vomiting

Dizziness

• Makes up a tremendous number of ER and Urgent Care visits.

• True persistent dizziness can lead to falls, and subsequent injuries and substantial day to day dysfunction of daily activities.

• Balance related falls leads to death in the elderly—i.e. hip fracture and subsequent blood clots and pulmonary embolus or subdurals but rarely are these falls due to VERTIGO

Dizziness

• Nonspecific when the patient walks in and says I am dizzy

• Your job is to figure out what the patient means by dizziness

• The key issue is whether the patient has true Vertigo a sense of rotation.

Dizziness

• There is a specific “Dizziness” clinic at Mayo’s• Classic paper by Daniel Drachman on the % of

patients with various symptoms who complain of dizziness

• True Neurological vertigo is RARE

Dizziness

• Vertigo Neurologic• Presyncope NON Neurologic• Disequilibrium Often Neurologic• Lightheadedness Rarely Neurologic

VERTIGO

• VERTIGO

Dizziness

• Vertigo, The illusion or sense of a spinning rotation of the room BUT it may be the patient who feels they are doing the spinning BUT there is a sense of rotation!

• Peripheral vs Central• Peripheral is a reflection of disorders of the

semicircular canals, utricle –the Vestibular End Organs or the 8th Nerve (ENT Docs say 8th nerve vertigo is central!)

• Central Vertigo implies dysfunction of the Vestibular Nuclear Connections or Cerebellum (less likely)

• The book is misleading on this point

Dizziness

• Peripheral Vertigo• Prominent Nausea and Vomiting• Unidirectional Nystagumus• Sudden Onset• Auditory Issues such as Hearing Loss or Tinnitus• May be positional• Very Disabling• Delay anf fatigue

Dizziness

• Central Vertigo• Nystagmus is variable• Less prominent nausea and vomiting• May not be disabling• Variable onset• No hearing issues• Other brainstem findings

Dizziness

• Presyncope• The sensation that one is about to faint• “feel faint”• Nausea• Dimming of Vision• Sweating• Tremor• Cardiovascular, Metabolic or much less likely

Hematologic in nature

Disequilibrium

• The sense one is about to fall• Motor weakness may cause this• Loss of sensory input from neuropathy may

cause this• Balance and gait are the issues!

Dizziness

• Lightheadedness• Non specific• Hyperventilation is the classic• Psych issues• Meds• Altered Sensorium• Non specific• My 8th grade auditorium

Dizziness

• Vertigo• Central Vertigo always requires immediate

evaluation including neuro imaging• Must eliminate the possibility of a posterior

fossa mass pressing on the brainstem or primary brainstem pathology.

Dizziness

• Peripheral Vertigo• Sudden Brief Attacks• Fall to the ground• Spells of Tumarken• No pre-syncope• No seizure stigmata• Nausea, vomiting and uni-directional nystagmus• Peripheral Nystagmus (Horizontal with a Rotatory

Component) Dampens with Fixation!

Dizziness

• Central Vertigo• Often a more gradual onset• They may not be able to walk but this may

reflect other issues including hemiparesis• Vertical Nystagmus is always of central origin• Unlike peripheral nystagmus central

nystagmus may persist beyond 48 hours.• Peripheral Vertigo always compensates over

time

Dizziness

• Brainstem Lesions Which Cause Vertigo• Always involves other tracts, motor, sensory

or other cranial nerve nuclei so look for signs of other deficits on Neuro exam

• Wallenberg’s Syndrome in the distribution of the Posterior Inferior Cerebellar Artery BUT usually due to vertebral occlusive disease is the classic brainstem syndrome causing vertigo

Dizziness

• Wallenberg’s• Infarction of Vestibular Nuclei• Ipsilateral Horner’s Sundrome• Ipsilateral Facial Numbness• Contralateral Limb Numbness• Dyphagia• Dysarthria• Diplopia

Dizziness

• Cerebellar Lesions Causing Vertigo• Cerebellar Infarcts (Medical Emergency)—

Swell and compress the brainstem (posterior Fossa Herniation Syndrome)

• Cerebellar signs- Past pointing, dysmetria, dysdiadokinesis (rapid alternating movements)

Dizziness

• Vertigo associated with transient Brainstem Ischemia

• Vertebrobasilar Insufficiency---diplopia, transient homonomous visual defects, dyarthria

• Drop Attacks VBI but patient does not lose consciousness

Dizziness

• Brainstem Stroke has a myriad of features!• Any stroke’s findings is a reflection of the affected

artery and it’s collateral blood flow• Opthalmoplegia• Hearing Loss• Visual Field Defects• Sensory Loss• Ataxia• MONOCULAR BLINDNESS IS ANTERIOR CIRCULATION

Dizziness

• Cerebellar Bleeds• Headache• Nausea Vomiting• Nystagmus• Ataxia of Gait• Depressed Level of Consciousness• EMERGENCY SURGERY!• Prevent Herniation of Cerebellum into the Brainstem

Dizziness

• Multiple Sclerosis

Dizziness

• Peripheral Causes of Vertigo Much More Common than Central Causes…Statistically whenever you see someone with severe Vertigo is usually peripheral.

Dizziness• BPPV (Benign Paroxysmal Positional Vertigo)• Most common cause of vertigo• Usually elderly• Positional One side or the other DOWN on the Pillow• Latency• Fatigue with repetitive episodes, Lasts 60 seconds per episode• Cupulolitiasis----Debris from the Utricle flowing freely in the

semi-circular canals endolymph• This acts as a plug like a plunger causing a push and pull effect

on the cupula creating asymetric neural impulses from the ears WHICH IS THE MECHANISM of Peripheral Vertigo and Nystagmus!

• Rolling Over in Bed much more often than LOOKING UP!

Dizziness• Vestibular Neuronitis• Probably akin to the same mechanism as Bell’s Palsy

(reactivation of latent Herpes Virus BUT affecting the vestibular portion of the 8th nerve)

• Often after a viral infection• May be a viral infection of the vestibular apparatus this is not

like the book says NUCLEAR this is PERIPHERAL NOT CENTRAL• Lasts weeks but the acute vertigo is over after about 48 hours

and the patient then feels disequilibrium for about 6-8 weeks. The vertigo can be recurrent during that time frame.

Dizziness

• Labyrinthitis• By definition there is a decrease in hearing

unlike vestibular neuronitis• The Labyrinthe is affected• Can be viral or bacterial or spirochetal• The end organ of hearing is involved by

definition• Otitis Media bacterial spread through a

ruptured membrane or a perilymph fistula

Dizziness

• These patients with labyrinthitis usually appear quite ill and have fever.

• Unlike vestibular neuronitis where fever is uncommon

• If you have Labyrinthitis there must be hearing loss and usually vertigo with nausea vomiting a peripheral pattern of nystagmus

• ENT Emergency

Dizziness

• Ramsay Hunt Syndrome• Varicella Zoster Virus reactivation• Affects Cranial Nerves 7 and 8• Facial Paresis• Tinnitus• Hearing Loss and Vertigo

Dizziness• Meniere’s Disease• Very Overdiagnosed..Occurs as attacks• Low Frequency Sensory Neural Hearing Loss is the HALLMARK

Hearing Loss may fluctuate• Increase in the volume of Endolymph which has led to various

therapeutic interventions• Distension of the Endolymphatic System• Severe Vertigo Nausea Vomiting with a peripheral pattern of

Nystagmus• Attacks last minutes to hours, Ear fullness or pain • Abrupt Spells of Tumarkan Fall to the Floor!• Usually unilateral but may be bilateral

Dizziness

• Acoustic Neuroma• Slow Unilateral Hearing Loss and Tinnitus• Schwanoma of the acoustic nerve• Begins on vestibular portion but affects

hearing first• Slow growth is the reason vertigo rarely

develops• Cranial nerves 5 and 7 This is the classic

cerebello-pontine angle lesion

Evaluation

• MRI

Pre-Syncope

• Simple Faint• Usually Needs to be differentiated from a

seizure• Post Episode Confusion Rare• No tongue biting• No incontinence• No shaking

Disequibirium• Patient feels unsteady, they feel like they are going

to fall.• Usually after a sudden change in position particularly

when they have lost visual cues.• Loss of sensory input• Motor weakness subtle affecting balance• Extrapyramidal Disease Parkinsons!• Visual Impairment with Neuropathy• Arthritis when it is severe• Long standing Diabetes or HIV

Lightheadedness

• Vague• Difficult to characterize• Most common in a dizziness clinic• Most important issue is that this is usually non

neurologic and usually not a sign of severe significant disease

• Floating sensation• Depersonalization a psych issue (anxiety,depression)• Hyperventilation

Evaluation• Patient may be uncooperative due to illness• Vital Signs Orthostatic BP Changes supine and

standing and look for a change in pulse• Complete HEENT and Neuro Exams• Nystagmus• EOM’s• Pupils• Fundus exclude Papiledema• Tympanic Membranes are CRUCIAL! (Scars,Fluid,Pus)• Weber Rinne after Gross Hearing

Evaluation

• Cardiac Exam Emboli• Carotid Bruits Emboli

• Neuro Exam• Gait Romberg is key• If you can’t stand with your feet together with

eyes open it is a cerebellar issue if it is only with eyes closed there is a sensory input issue.

Evauation• Dix-Hallpike Maneuver• Diagnose BPPV• Turn Head 45 degrees to the side being tested• Rapidy lower head to a position hanging below the examing

table• Eyes open (nustagmus and Vertigo)• After a short latency a positive test is denoted by the eyes

having a burst of nystagmus with the eyes beating towards the ground (fast phase component of nystagmus)

• Lasts a minute or so• Posterior Canal Variant of BPPV

Dizziness

• Always hyperventilate the patient if need be to dx

• Reproducing the syomtoms is the key to understanding whats wrong in non obvious cases

Evaluation

• Labs Not Helpful Diagnosing Vertigo• CBC (anemia)• Chem Profile (eletrolytes)(dehydration BUN)• Thyroid Tests• Glucose Tolerance Test (hypoglycemia)• EKG afib or arrythmia of other type ???echo

Evaluation

• Electronystagmography• Records eye movements to look for

nystagmus• In response to vestibular,visual,

cervical,caloric, rotational,positional stimulations to assess vestibular function

• Audiogram KEY Meniere’s Low Frequency Sensorineural Hearing Loss

Evaluation

• ENG

Evaluation

• Audiogram

Evaluation

• ENG

Evaluation

• ENG

Evaluation

• MRI